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rQ �a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR FF CE USE: , 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �- <br /> (complete In Triplicate) <br /> Application is hereby made to the San -Joaquin Local 'Health District for a permi°t to construct <br /> and/or install the work herein described. This applicat-ion -is made in compl.ian�ce with San <br /> Joaquin County Ordinance No. 1862 and the °Rules and Regulations of the San- Joagain Local health <br /> District. 9 <br /> EXACT STREET ADDRESS <br /> apr.2 ype .r p. 11jr v TY/SOWN CYae�. <br /> uOwner's Name " Phone--.- .I <br /> Address • ..Ci ty.. <br /> Contractor's Name - Li cense#,a--7xj'`Phone i- :Z!,?-/— - <br /> IS CERTIFICATE OF WORKMAN'S CO", ENSATION INSURANCE ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NE ._--- .. ------ -� . <br /> W WELL 0 J DEEPEN ❑ RECONDITION ❑ DESTRUCTION d l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR�!] PUMP REPLACEMENT'Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS�L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL------ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well- Excavation iM <br /> Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing i. <br /> _—_Irrigation Gravel Pack Depth of Grout Seal--- <br /> Cathodic <br /> ea Cathodic Protection Rotary Type of Grout N . ip <br /> Disposal Other Other Information iM <br /> - Geophysical Surface Seal Insta ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. .Or— <br /> PUMP REPLACEMENT: G]State­Work 'Done <br /> PUMP REPAIR: State Work Don eG,�/�-.r <br /> DESTRUCTION OF WELL: Well Diameter Approximate'�Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of tie San Joaquin 'Local <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance. of the work for which' this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPE ON R GROTING AND `A-FINAL INSPECTION. <br /> SIGNED - ITLE: r~e�s DATE: Y <br /> A412 <br /> VO <br /> R PL L ON REVERSE SIDE)--- <br /> FOR DEPART%1T USE .ONLY <br /> RHASE I - <br /> APPLICATION ACCEPTED. BY DATE <br /> ADDITIONAL COMMENTS: J1. <br /> PHAIE, II GROUT. INSPECTION PHASE III FINAL :INSPECTION <br />(INSPECTION BY - INSPECTION BY-"",— � DATE 311 7 <br /> :. DATE At q <br /> ~': 14 26 RPV_ q/7R - 9/7R 7M <br />